Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report

Source:  BMJ Quality & Safety 24/5 pp. 337-44

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Date of publication: May 2015

Publication type:  Journal article

In a nutshell: Staff at Great Ormond Street Hospital developed and tested a tool specifically designed for patients and families to report harm. Processes to report harm were developed over a 10-month period. The tool was tested in different formats and it moved from a provider centric to a person-centred tool analysed in real time. Feedback to staff provided learning opportunities. Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is vital to achieve safety. The testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised awareness.

Length of Publication:  8 pages

Implementing the Safety Thermometer tool in one NHS trust

Source:  British Journal of Nursing 13-26 23/5 pp. 268-72

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Date of publication:  March 2014

Publication type:  Journal article

In a nutshell:  The NHS in England introduced the NHS Safety Thermometer to address measurement of patient safety using the Commissioning for Quality and Innovation (CQUIN) scheme. This article discusses the CQUIN scheme and the thinking behind the focus on pressure ulcers, falls in care, catheter use and urinary tract infection, and venous thromboembolism. The implementation of the scheme in a large NHS foundation trust is described together with its effect within the authors’ organisation on harm-free care for their patients.

Length of Publication:  5 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.

The measurement and monitoring of safety

Source:  The Health Foundation

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Date of publication:  April 2013

Publication type:  Report

In a nutshell:  There is now a great awareness of the problem of medical harm, and significant efforts have been made to improve the safety of healthcare. The authors have synthesised available evidence and have proposed a single framework that brings together a number of conceptual and technical facets of safety. This framework highlights five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a widespread and rounded picture of an organisation’s safety. The dimensions are past harm, reliability, sensitivity to operations, anticipation and preparedness, and integration and learning.

Length of Publication:  92 pages

Safe and effective service improvement: delivering the safety

Source: Amnis

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Date of publication: May 2011

Publication type: Guidance

In a nutshell: These guidance notes look at implementing Lean as a method of improving patient safety.  This approach looks at reducing costs, time and supplies.  It can also reduce the number of near misses through events that can result in severe death or harm to a patient.

Length of publication: 27 pages